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I LAPPLICATION FOR PERMIT L. SAN JOAQUIN LOCAL HEALTH DISTRICT r 1601 E. 11AZE;LTON AVE., STOCKTON, CA Telephone [209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin I Local Health District.',. E X 15T,/�✓G L d r .. , 2�GoQ1f3 Job Address 987 City SQA) Lot Size 106Y 31 D PM } or--sus_ S p//ViI SA Address Phone `�88 Owner's Name Contractor ;4ddressIoC1.� ll• L11_&IAAl AtI4_ License No.4�Ti!'Tf7�_Phone46-f--3972 TYPE OF WELL/PUMP: k NEW WELL'-0 `,� WELL REPLACEMENT ❑ DESTRUCTION ❑ r PUMP INSTALLATION$❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK F- SEWER'LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL —-OTHER WELL PITS/SUMPS _ INTENDED USE I TYPE OF WELL PROBLEM AREA'-,CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open.Bottom ❑ Manteca Dia. of Well'Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel El. 1111'e Type of Casing Specifications ❑ Public ❑Other ` ,'❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ° pprox. Depth ❑ Eastern ESurface Sea! Installed by I Repair Work Done ❑ Type"of Pump H:P- f 4.`- State Work Done Well Destruction O Well'Diameter K t Seal n , 501 Depth Filler Material IBelove'50'I =' TYPE OF SEPTIC WORK: NEW INSTALLATIOW9 REPAIRIADDITION ❑ DESTRUCTION ❑ lNo-geeptic"'system permitted if public sewer is �. ✓ C- available within 200 feet.) Installation will serve: Residence— Commercial_ Other �- Number of living unm its:�_ Nuber of-bedrooms Character of soil to a dep of 3 feet: CSA Water table depth 'x-a SEPTIC TANK Type/Mfg O- � ' Capacity ZO Q No. Compartments PKG. TREATMENT PLT. Elfrf. Method of Disposal Distance..tosearest:_ Well, 1 � Foundation_ I D Property Line 45 s1A P4_1 LEACHING LINE No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation ISI _ Property Line 5 y f SEEPAGE PITS 1 ❑ Depth 1 /a, Size e2 X 11 X Number m 1 SUMPS 5 Distance to nearest: - Well &/4 Foundation %Od Property Line DISPOSAL PONDS ; ❑ .I �, `,y , I hereby certify that I have prepared this application a, 4d that the work will be done in accordance with San Joaquin county ordinances, state laws, and i rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for /all required inspections. Complete drawing on reverse side. Signed )r�Lfr.nol' �(Jyr,trf M Title: Date: ? St ' r F�EPARTMENT USE ONLY Application Accepted` Dated UrCZ p Area Pit or Grout Inspection Date Final Inspection b Date Additional Comments: 4 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 82:3-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton-Ave., P.O. Box 2009, Stk., CA 95201 , FEE CAS,.,,.AMOUNT DUE-..�_�—AMOUN.T-REMITTED..;. CK H-1—RECEIVED BY DATE PERMIT NO. 1NF0 + EH 1324 IREV. Fr Z � EH 14-28 ` I _ i